Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania and affiliates
Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania and affiliates
Summary of Dental Benefits and Coverage Disclosures Matrix (SDBC) Document Library - California
| Plan name | Group | Division |
|---|---|---|
| Delta Dental Individual & Family™ Delta Dental PPO™ Family Dental PPO* (2025 version) | 50037 | 10004 |
| Delta Dental PPO™ Children's Dental PPO* for Small Businesses (2025 version) | This plan is associated with a number of Groups/Divisions and are not listed here | |
| Delta Dental Individual & Family™ DeltaCare® USA** Family Dental HMO (2025 version) | This plan is associated with a number of Groups/Divisions and are not listed here | |
| DeltaCare® USA Children's Dental HMO** for Small Businesses (2025 version) | 77036 | 00124, 00134, 00144, 00154 |
| DeltaCare® USA Family Dental HMO for Small Businesses (2025 version) | 77036 | 00172, 00182, 00192, 00202 |
| Delta Dental Individual & Family™ Delta Dental PPO™ Family Dental PPO * (2024 version) | 50037 | 10004 |
| Delta Dental Individual & Family™ DeltaCare® USA Family Dental HMO ** (2024 version) | 78637 | 00024 |
| Delta Dental PPO™ Children's Dental PPO for Small Businesses * (2024 version) | This plan is associated with a number of Groups/Divisions and are not listed here. | |
| Delta Dental PPO™ Family Dental PPO for Small Businesses * (2024 version) | This plan is associated with a number of Groups/Divisions and are not listed here. | |
| DeltaCare® USA Children's Dental HMO for Small Businesses ** (2024 version) | This plan is associated with a number of Groups/Divisions and are not listed here. | |
| DeltaCare® USA Family Dental HMO for Small Businesses ** (2024 version) | This plan is associated with a number of Groups/Divisions and are not listed here. | |
| Plan name | Group | Division |
|---|---|---|
| DeltaCare® USA - CAA50 Senior Program** (2025 version) | 70530 | 00002, 00004, 00005, 00006, 01005 |
| DeltaCare® USA - CAA55** (2025 version) | 70116 | 00008 |
| DeltaCare® USA - CAA54** (2025 version) | 70116 | 00009 |
| Delta Dental PPO™ - Individual Basic *** (2025 version) | 18818 | 00004 |
| Delta Dental PPO™ - Individual Premium*** (2025 version) | 18818 | 00005 |
| DeltaCare® USA – CAA50 Senior Program ** (2024 version) | 70530 | 00002, 00004, 00005, 00006, 01005 |
| DeltaCare® USA – CAA55 ** (2024 version) | 70116 | 00008 |
| DeltaCare® USA – CAB54 ** (2024 version) | 70116 | 00009 |
| Delta Dental PPO™ – Individual Basic *** (2024 version) | 18818 | 00004 |
| Delta Dental PPO™ – Individual Premium *** (2024 version) | 18818 | 00005 |
| Plan name | Group | Division |
|---|---|---|
| Delta Dental PPO Protect Plus **** (2025 version) | 1230 | 10505,00505, 20505, 30505 |
| Delta Dental PPO Protect **** (2025 version) | 1230 | 10504. 00504, 20504, 30504 |
| Delta Dental PPO Protect Propel**** (2025 version) | 22441 | 00506 |
| DeltaCare® USA Essential** (2025 version) | 7677 7, 76976 | 01001 |
| 15B DeltaCare® USA ** (2024 version) | 76777 / 76976 | 01001 |
| Delta Dental PPO Plan A **** (2024 version) | 01230 / 17104 | 00501 |
| Delta Dental PPO Plan B **** (2024 version) | 01230 / 17104 | 00502 |
| Plan name | Group | Division |
|---|---|---|
| DeltaCare® USA - CAE01** (2025 version) | 76444 | 00001 |
| DeltaCare® USA – CAE01 ** (2024 version) | 76444 | 00001 |
If you live in CA and would like a paper copy of the Summary of Dental Benefits and Coverage Disclosure Matrix SDBC, free of charge, please call our Contact Center at 888.282.9501.
The SDBCs are just summaries. Review the plan booklet and disclosure form for a complete description of benefits, limitations and exclusions.
*In CA, Delta Dental PPO is underwritten by Delta Dental of California.
Please refer to the policy and disclosure form for a complete list of plan benefits, limitations and exclusions.
**In CA, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products.
Please refer to the policy and disclosure form for a complete list of plan benefits, limitations and exclusions.
***In CA, Delta Dental PPO is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company.
Please refer to the policy and disclosure form for a complete list of plan benefits, limitations and exclusions.
****In CA, the AARP® Dental Insurance Plan is insured by Dentegra Insurance Company (Contract 1230) and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products.
Please refer to the plan COC and disclosure form for a complete list of plan benefits, limitations and exclusions.
AARP endorses the AARP Dental Insurance Plan, administered by Delta Dental Insurance Company. Delta Dental Insurance Company pays royalty fees to AARP for use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.